Covid-19: one more tragedy to come for Syrian refugees

Distribution in Deir Hassan camp. The settlements are overcrowded with 120 000 displacled people. Credit: Abdul Majeed Al Qareh

The North West in Syria is currently the area most affected by the conflict where daily bombing and shelling have displaced almost one million people from their homes in the space of just a few months. The COVID-19 pandemic has added another layer of complexity to a catastrophic humanitarian emergency according to Médecins sans Frontières (MSF), based in Geneva.

Why are we talking about it. As 14 cases and two deaths of Covid-19 have already been reported in the government-led area (figures moving daily), the province of Idlib is preparing for the worst. Thousands of displaced people fleeing the bombings that raged between December 2019 and March 2020 have taken refuge in the area. “An emergency that will add to another emergency," warned the Head of Mission of MSF in Syria.

In Deir Hassan camp alone, 164 000 people still need tents, mattresses, plastic sheeting, blankets, cooking utensils and toiletries in various scattered sites. In some, like Latamneh, "there are still no latrines, no sewage disposal and no proper roads", said Manaf Shamma, a displaced mother. There are also those in the region of Afrin further north, controlled by Turkish forces, where many displaced families have settled in empty houses, factories or public buildings. Or those in Boul Boul, a site still under development. Facing a pandemic amid a humanitarian crisis could very quickly become catastrophic, warned the medical humanitarian organisation.

"We saw people sitting outside with nothing; we also saw two or three families sharing a tent with no protection from the cold or rain. And too few tents to accommodate the new arrivals”, said Ahmed, MSF project team leader.

How can we ensure quarantine in these conditions?

Quarantine almost impossible to set up. “We're faced with this dilemma. For moderate cases with symptoms that do not require hospitalization, we will not be able to tell people, "Go home, but don't be in contact with your loved ones.” We don't have a solution", said Hakim Khaldi, MSF Head of Mission in Syria. "It might be possible to isolate an infected person in urban areas, but for families sharing a tent, isolating for at least two weeks becomes very complicated. “

“Most recommendations for protecting people against the virus and slowing down the spread of the epidemic simply cannot be implemented in Idlib. How can you ask people to stay at home to avoid infection? Where even is their home? We are talking about almost one million displaced people – at least one-third of Idlib’s total population – most of them living in tents in camps.” confirms Cristian Reynders, MSF Field Coordinator in Northwest Syria

For severe cases, the situation is even more problematic. Today in Idlib, there is no existing structure to deal with them. More than 35% of the patients in MSF mobile clinics are already suffering from respiratory infections. "A potential spread of the virus could quickly lead to complications," says Cristian Reynders. The health infrastructure is insufficient to meet the needs of so many people, increasing the risk of waterborne diseases. The ten year-long war has put more than 80 hospitals out of service and the healthcare system in Northwest Syria is already stretched to its limit.

Since 26 March, WHO has been providing PCR screening tests to Idlib's Central laboratory to test suspected cases, and teams are collecting and processing the samples. Earlier this week, 15 people tested negative. But "it's not a relief, because one laboratory is not enough", said Khaldi. The real issue in Idlib is the number of resuscitation beds in relation to the total population. And the question is not “if”, but “when” the virus will be there.

“MSF is putting everything they can in place, but it will probably not be enough if Covid-19 starts spreading in Idlib province”, warned Cristian Reynders.

Getting ready at the expense of other emergencies. The first phase consists of training medical personnel: identification of symptoms, minimal care and infection control measures (IBC). MSF has set up hygiene committees in three different hospitals and new triage systems in these facilities to better identify and isolate suspected Covid-19 patients. The organization has suspended its mobile teams in Deir Hassan, Afrin and Boul Boul camp to allow staff to be trained in infection prevention and control and to prevent the spread of the virus. But medics need to prioritise constantly: get trained up and ready in case the pandemic reaches Idlib or deal with the never-ending flow of patients coming for treatment. They are faced with impossible choices. “Should we stop our work in the camps to prevent people gathering in front of our mobile clinics or during our distributions of essential items? Are we protecting people if we stop our activities, or are we depriving them of essential services and therefore potentially putting their health at greater risk?” asked Cristian Reynders.

Next week, MSF will send sensitizer agents to train the population and distribute hygiene kits (soap, bleach and washing powder) so people can wash their hands and clothes and disinfect their tents. "In the camps, we've also started implementing measures of social distancing when providing our regular services. When running mobile clinics, we now only allow small groups of people to gather around our trucks while waiting for consultations. During distributions of essential items, we ask people to keep a certain distance between each other", said Cristian Reynders. But it’s easy to say in an environment with no confirmed cases. "It’s like everywhere else in the world, before the virus affected their loved ones, people didn’t realize how dangerous it was and how it can affect their daily lives," explained Hakim Khaldi.

The challenge of WHO response plan. A draft Covid-19 response plan by WHO suggests making three hospitals available for severe cases with oxygenation equipment, set up 28 community bed isolation in tents dispatched in the camp to quarantine less severe cases, triage tents in all Health centers and reinforce the existing lab, but it’s not operative yet. The only structure in fonction at the moment is the lab and the sample collection. MSF would also like to set up a hospital for moderate cases. MSF's burn ward has a three-month capacity for masks, gloves and hydrogel, but they need protective equipment for the other centers. Essential supplies, medicines, medical equipment (especially oxygen concentrators), protective equipment and international staff to support the local teams are still lacking. Not to mention the routing challenge." The restrictions came first from Europe followed by Turkey the past week. Countries must allow us to export, the whole chain must work", called Hakim Khaldi.